key: cord-0786447-s9f9bhpt
authors: Hardman, Gillian; Sutcliffe, Ruth; Hogg, Rachel; Mumford, Lisa; Grocott, Laura; Mead‐Regan, Sarah‐Jane; Nuttall, Jane; Dunn, Stephanie; Seeley, Philip; Clark, Stephen; Quigley, Richard; Al‐Attar, Nawwar; Booth, Karen; Dark, John H.; Fisher, Andrew J.
title: The impact of the SARS‐CoV‐2 pandemic and COVID‐19 on lung transplantation in the UK: Lessons learned from the first wave
date: 2021-02-01
journal: Clin Transplant
DOI: 10.1111/ctr.14210
sha: ed973e08e9e4ea6da02c96cf9fe8e83bd73779ed
doc_id: 786447
cord_uid: s9f9bhpt

BACKGROUND: Lung transplantation is particularly susceptible to the impact of the severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2) pandemic, and evaluation of changes to practice is required to inform future decision‐making. METHODS: A retrospective review of the UK Transplant Registry (UKTR) and national survey of UK lung transplant centers has been performed. RESULTS: There was geographic variation in the prevalence of COVID‐19 infection across the UK. The number of donors fell by 48% during the early pandemic period. Lung utilization fell to 10% (compared with 24% for the same period of 2019). The number of lung transplants performed fell by 77% from 53, March to May 2019, to 12. Seven (58%) of these were performed in a single‐center, designated “COVID‐light.” The number of patients who died on the lung transplant waiting list increased, compared to the same period of 2019 (p = .0118). Twenty‐six lung transplant recipients with confirmed COVID‐19 infection were reported during the study period. CONCLUSION: As the pandemic continues, reviewing practice and implementing the lessons learned during this period, including the use of robust donor testing strategies and the provision of “COVID‐light” hospitals, are vital in ensuring the safe continuation of our lung transplant program.

and changes to practice, with early reports from across the world identifying significant decreases in solid organ transplantation, [3] [4] [5] [6] [7] including lung transplantation 8, 9 programs, in response to the pandemic.

As a novel disease, and unprecedented global pandemic, the evidence base informing practice was initially limited, albeit growing rapidly throughout the course of the pandemic. During the early phase in the UK, guidance for solid organ donation was issued at a national level, from National Health Service Blood and Transplant (NHSBT), with individual organ programs, and transplant centers, making decisions locally, based on the needs of their transplant patient population, balancing the risks of COVID-19 infection, and the prevalence of the disease locally, and its subsequent impact on hospital resource.

As the pandemic continues, evaluation of national and regional changes to lung transplant practice in the UK, and their impact on the patient population, during the early phase of the pandemic, is required, to inform future decision-making. The aim of this work was to understand changes to clinical practice during the early pandemic period and the impact of these changes on the UK lung transplant program.

All adult and paediatric lung transplant centers in the UK were included in the study. Analysis included all adult (aged 16 years and older) and pediatric organ donors, lung transplant waiting list candidates, and lung transplant recipients. Heart-lung candidates and recipients were not included in the analysis.

A retrospective review of data submitted to the UK Transplant Registry (UKTR) from January 1, 2019, to June 30, 2020, was performed. The early pandemic period is defined here as March 1 to May 31, 2020. Month-to-month and center-level variation in practice was reviewed from January 1 to June 30, 2020, to include the early pandemic period, and, where appropriate, compared to data from January 1 to June 30, 2019. To explore regional, center-level variation in clinical practice and policy, during the pandemic, a national survey of UK transplant centers was performed.

The survey was developed using an iterative process based on literature review and UK organ donation and transplantation guidance issued by NHSBT and the British Transplant Society, to identify changes in lung transplantation clinical practice, including candidate assessment, recipient management, organ donation, and activity, perceptions of the prevalence of COVID-19 locally and the impact on the transplant workforce and hospital resource. The final survey was approved by members of the NHSBT Cardiothoracic Advisory Group Clinical Audit Group (CTAG CAG).

The NHS England coronavirus specialty guide cardiothoracic Conclusion: As the pandemic continues, reviewing practice and implementing the lessons learned during this period, including the use of robust donor testing strategies and the provision of "COVID-light" hospitals, are vital in ensuring the safe continuation of our lung transplant program.

coronavirus pandemic, COVID-19, lung transplantation, organ donation, SARS-CoV-2 escalation framework 10 was used to define phases in response to the pandemic.

The survey was conducted between May 15 and June 18, 2020. At each center, a cardiothoracic transplant clinical lead and transplant coordinator were identified to complete the survey. Participants were emailed a copy of the survey. Information required to complete the survey was gathered by the nominated persons, from members of the wider team. Additional telephone interview follow-up was performed between June 20 and July 13, 2020, where further information was required, or to clarify specific survey responses. 

The survey return rate was 100%. Additional information and clarification of responses were performed by telephone interview with 3 of the 6 UK lung transplant centers. Table 1 .

At the time of the survey, all centers considered themselves to be moving into the recovery phase; however, a date for return to "normal" (pre-pandemic) service had not been identified in any center. All centers recognized that changes to clinical practice, adopted during the pandemic, would persist. Table 3 . There was a significant decrease in donor age (from a median age of 52 in 2019

to 43 years during the pandemic period, p = <.0001) and a significant increase in the proportion of donors with a smoking history (53% in 2019 to 66% during the pandemic period, p = .0180).

The lung utilization rate during the early pandemic period was 10%, 13 donors transplanted from 123 donors (who donated at least 1 solid organ) where the lung(s) were offered. One donor was utilized outside of the UK. This compares to a utilization rate of 22%, for the same period of 2019.

In the survey responses, all centers described formal or informal, center-level changes to lung donor acceptance criteria during the pandemic. Changes described included consideration of ideal donors only, lower age limits for potential donors and increased caution when considering travel and ischemic times.

All centers reported a period of restricting lung transplantation to urgent or super-urgent, inpatient candidates only, at the start of the pandemic. Decision-making was based on local hospital guidance, limiting access to ICU for non-urgent patients, and consideration of potential risks to non-urgent lung transplant candidates. Following designation as a "COVID-light" hospital, 1 center continued to consider all lung transplant candidates from early April onwards. The remaining centers adopted center-level policy to consider non-urgent, ultra-low, and low-surgical risk candidates from late-April 2020,

where appropriate, balancing resource capacity. Table 4 .

The number of new registrations to the lung transplant waiting list fell by 68% ( 

All centers reported that active efforts had been made to reduce hospital attendance for lung transplant recipients. At the time of the survey, in all cases, these changes were planned to continue.

Face-to-face follow-up has been reduced to only those within the As the pandemic continues, and a greater number of individuals in the general population are exposed to, or will have previously tested monitoring and communication, provides an area for further development and quality improvement in practice. Funding for this innovation, and ensuring equity of access for the patient population, will be required, and understanding the impact of such changes, and the pandemic more widely, on the psychological well-being of the lung transplant patient population provides a potential area for future study.

Hopes that the pandemic would peak and resolve after spring 2020 in the UK are fading. It is increasingly evident that this pandemic will move in waves and, at the time of writing, the volume of cases is once again rising. Anecdotally, center-level decisions surrounding lung transplant activity, are once again being made. As experience in the management of the most severely affected COVID-19 patients grows, it is hoped that the impact of case volume on hospital resource will be less acutely felt than earlier in the year. However, the risks specific to lung transplant candidates, recipients, and the potential lung donor population will not disappear. As evidenced here, continuing activity is vital for the candidate population. 

The data that support the findings of this study are available from the corresponding author upon reasonable request.

https://orcid.org/0000-0001-9600-4097

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